Managing End-of-Life Care: Comparing the Experiences of Terminally Ill Patients in Managed Care and Fee for Service


Address correspondence to Ezekiel Emanuel, Department of Clinical Bioethics, Warren G. Magnuson Center, 10 Center Drive, Bldg. 10, Room 1C118, National Institutes of Health, Bethesda, MD 20892. E-mail: eemanuel@nih.govL


There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient-physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end-of-life care, care needs, and economic burdens.

Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P = .02), spend more than 10% of their income on medical care (P = .02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P = .03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P = .59). Despite concerns about the threats of MCOs to the physician-patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.